Autonomic Dysreflexia (AD) is an unpredictable, potentially life-threatening condition whereby there is a sudden, rapid and uncontrolled increase in blood pressure. Autonomic dysreflexia is a medical emergency that can occur in people who have a spinal cord injury (SCI) at or above the sixth thoracic (T6) level. It is the body’s abnormal response to a painful or harmful stimulus, such as an overfull bladder or bowel. This abnormal response causes an abrupt rise in blood pressure.

Before SCI, such a stimulus would have caused pain or discomfort. However, with SCI, one loses feeling below the level of the injury. Therefore, the same stimulus goes unnoticed, and the body can’t respond properly to signals that something is wrong resulting in AD. The resolution of AD requires quick and decisive treatment.

The Basic Principle in Autonomic Dysreflexia
“Any athlete who exhibits signs and symptoms of Autonomic Dysreflexia shall be removed from the event, and actions to bring down the elevated blood pressure should be initiated immediately.”

Definition
Autonomic dysreflexia (AD), with its sudden and severe rise in blood pressure, is a potentially life-threatening condition that can occur in anyone with a spinal cord injury (SCI) at or above thoracic level six (T6). It is a serious condition which if ignored or improperly managed can lead to serious consequences including death.

Athlete and team responsibilities

• Ensuring that their athletes are not using mechanisms intentionally which may cause or provoke dysreflexia (boosting)
• Removing an athlete from competition if the athlete becomes dysreflexic
• Cooperating with WWR personnel in examining players who may be dysreflexic

Autonomic Dysreflexia Examination If Evidence of AD Symptoms

The examination should be conducted by qualified medical or paramedical with knowledge of AD. Teams are required to provide any requested assistance.

Examination should include an assessment of the presence of symptoms of dysreflexia, followed by measurement of the athlete’s blood pressure. An athlete with a systolic blood pressure of 160 mmHg or above is considered to be in a hazardous dysreflexic state.

Prior to competition

• If systolic blood pressure is increased 20-40 mmHg above the athlete’s baseline (15-20 mmHg in children) or measures 160 mmHg or higher, the athlete will not be permitted to play
• Causes of increased blood pressure will be investigated by the qualified medical or paramedical personnel and the athlete, and subsequent treatment pursued if the cause is identified
• A re-examination will be done ten minutes later. If blood pressure remains above the baseline, the athlete will be removed from the roster for that game
• If the blood pressure has declined to a non-hazardous level, the athlete will be permitted to enter the game at the next opportunity

During competition

• An athlete may be examined at any time during the game
• All requests to test an athlete during a game are to be made to the athlete’s Head Coach
• The Coach should evaluate and cooperate with all such requests if deemed necessary

Causes of Autonomic Dysreflexia

• Bladder distension
• Catheter blockage
• Urinary tract Infection
• Urethral trauma
• Bowel distension/impaction

• Constrictive clothing, shoes, or equipment
• Insult to skin (pressure on skin by objects, sunburn, cuts, frostbite, blisters)
• Ingrown toenails
• Gastric ulcer/gastritis
• Pregnancy

Signs and Symptoms

• Sudden increase in blood pressure above normal (20 to 40 mmHg above baseline)
• Pounding headache
• Bradycardia (low heart rate below the individual’s baseline)
• Profuse sweating above the level of injury (LOI)
• Piloerection (goosebumps) above the LOI
• Flushing of the skin above the LOI

• Cardiac arrhythmia (irregular heartbeats)
• Blurred vision
• Spots in visual fields
• Nasal congestion
• Feeling of apprehension or anxiety
• Minimal or no symptoms despite increase in blood pressure (silent AD)

Immediate Management Protocol

Management must concentrate on identifying causation and removal of the stimulus.

Lower blood pressure

• Sit up if lying down
• Take blood pressure and HR
• Check the bladder status (is there anything causing abnormal drainage)
• Take the blood pressure medication prescribed by the healthcare provider if indicated

Remove the harmful stimulus

• Unblock blocked catheters
• Loosen restrictive clothing/tapes
• Bowel disimpaction
• Identify and remove pressure causing object(s)

Advanced Management Protocol

If the player does not respond to immediate actions: initiate local emergency medical protocol

Non-AD Hypertensive athletes

If an athlete with a spinal cord lesion has essential hypertensive risk, the athlete should obtain medical evaluation AND clearance prior to competition

Boosting

• Boosting is the intentional induction of a state of autonomic dysreflexia with the aim of performance enhancement. This leads to significant increase in blood pressure prior to competition which can be life threatening. This is equivalent to a doping violation.
• Any deliberate attempt to induce autonomic dysreflexia in competition endangers the health and welfare of the athlete and team management should make this very clear to the athletes and staff

• Boosting in competition is forbidden
• If there is evidence of deliberate attempts of boosting, this will be reported to WWR for subsequent investigation
• If there is any evidence of involvement by athlete support personnel in assisting an athlete’s deliberate attempts to induce dysreflexia (boosting) it will also be subject to investigation

Download the WWR Medical Protocol for Autonomic Dysreflexia

Contributors:
Kristin Garlanger, DO
Spinal Cord Injury Consultant, Mayo Clinic, Rochester, MN

Kenneth Lee, MD
Chief of Spinal Cord Injury Division, Clement J Zablocki VA Medical Center, Milwaukee, WI

Jim Murdock
Medical Coordinator / Athletic Trainer USA Wheelchair Rugby

Blood and other bodily fluids such as urine and feces present a safety risk to players and officials due to the risk of spread of infectious diseases through contact with the fluid. There is also a risk to the bleeding player of infection through contact with other players.

To protect the health and safety of our athletes, and others engaged in our sport, WWR has adopted the following guideline regarding bodily fluid. All athletes, coaches, team support staff and technical officials including referees have a responsibility to ensure that they are identified and managed effectively.

Process: Blood

• Any items of clothing or equipment that are contaminated by blood must be replaced, cleaned or covered
• During the time-out, any blood contamination of the ball or the court should be cleaned
• Referees may extend the time-out to allow for the cleaning process of the court and ball or replacement of the ball
• If the referee or a player notices blood on the court or the ball, but the player who is bleeding cannot be identified, the referee will call a Referee’s Time-out
• The team management will check all their players on the court to determine the source of the bleeding

Process: OTHER bodily fluids (ie: urine, stool, vomit, etc.)

• Any items of clothing or equipment that are contaminated by the bodily fluid must be replaced, cleaned or covered
• During the time-out, any contamination of the ball or the court should be cleaned
• Referees may extend the time-out to allow for the cleaning process of the court and ball or replacement of the ball
• If the referee or a player notices bodily fluid on the court or the ball, but source of the fluid cannot be identified, the referee will call a Referee’s Time-out
• The team management will check all their players on the court to determine the source of the bodily fluid contamination

Summary and Conclusion

Let us keep our sport, athletes, staff and officials safe

Download the WWR Body Fluid Guidelines

Contributors:
Kenneth Lee, MD
Associate Professor, Dept of Phys Med & Rehab, Medical College of Wisconsin, Milwaukee, WI

Jim Murdock
Medical Coordinator / Athletic Trainer USA Wheelchair Rugby

The basic principle in all sports-related concussions
“Any athlete who exhibits signs, symptoms or behaviours consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion, or balance problems) shall be immediately removed from the contest and shall not return to play until cleared by an appropriate health care professional.”

WHEN IN DOUBT…. SIT THEM OUT

Definition

Signs and Symptoms

Failure to answer any of the following questions correctly may suggest a concussion:

• “What venue are we at today?”
• “Who scored last in this game?”
• “What team did you play last game?”
• “Did your team win the last game?”
• Any question of common knowledge

Actions to take with athletes with a suspected concussion

• Remove immediately from play (training, practice or game)
• Refer the athlete to a qualified healthcare professional
• Initial treatment requires physical and cognitive rest
• The athlete begins a graded return to play protocol
• Medical clearance is required for return to play
• Documentation of all evaluations and processes

Any athlete with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY, using appropriate emergency management principles. Once safely removed from play they should be evaluated by a physician or other licensed healthcare provider prior to returning to play.

If a neck injury is suspected, the player should only be removed by authorized healthcare professionals (AHP) with appropriate spine care training.

Teammates, coaches, medical staff, officials, team managers, or administrators who suspect a player may have concussion MUST ensure that the player is removed from the field of play in a safe manner.

A player with any symptoms/signs or a worrisome mechanism of injury has a SRC until proven otherwise. No athlete should Return to Play (RTP) or practice on the same day of a concussion.

Any athlete suspected of concussion should be evaluated by a licensed healthcare provider on that day.

Any athlete with concussion should be medically cleared by a physician or other licensed healthcare provider prior to resuming practice or competition. (see Return to Play)

Advanced Management Protocol

Evaluate the player on the sideline, or in the locker room using the SCAT5 or other sideline assessment tools.

• Ask about concussion symptoms
• Examine for signs
• Verify orientation (What day is it? What is the score? Who are we playing?)
• Check immediate memory (repeat a list of 5 words)
• Test concentration (list the months in reverse order)
• Test coordination if possible (have the athlete attempt a sport-related task that would normally be easily completed)
• Check delayed recall (repeat the previous 5 words after 5-10 minutes)
• Check vital signs, HR and BP
• Document your findings and procedures

** If a healthcare provider is not available, the player should be safely removed from practice or play and have urgent referral to a licensed healthcare provider arranged.

An athlete who is symptomatic after a concussion initially requires physical and cognitive rest.

• A concussed athlete should not participate in physical activity, return to school, play video games or text message if he or she is having symptoms at rest
• Concussion symptoms & signs evolve over time and the severity of the injury and estimated time to return to play are unpredictable.

Return to Play (RTP)

• Under the GRTP program, the player can proceed to the next stage only if there are no new symptoms or worsening symptoms of concussion during rest and at the level of exercise achieved in the previous GRTP stage
• If any new or worsening symptoms occur while going through the GRTP program, the player must return to the previous stage and attempt to progress again after a minimum 24-hour period of rest without symptoms
• WWR recommends that a medical practitioner or approved healthcare professional confirm that the player can take part in full contact training before entering Stage 5

Graduated Return to Play Protocol

Stage 4: Non-contact training drills
Exercise allowed: Progression to more complex training drills, e.g. passing drills. May start progressive resistance training.
Objective: Exercise, coordination and cognitive load

Stage 5: Full contact practice
Exercise allowed: Normal training activities
Objective: Restore confidence and assess functional skills by coaching staff

Stage 6: Return to play
Exercise allowed: Player rehabilitated
Objective: Recover

Resistance training should be added only in the later stages (stage 3 or 4 at the earliest).

If symptoms are persistent for more than 10–14 days in adults the athlete should be referred to a healthcare professional who is an expert in the management of concussion.

Return to Play in Competition

Documents:
Concussion recognition tool
SCAT5
WWR Concussion Guidelines

Practicing good personal hygiene is one of the simplest and most effective ways to protect yourself and others from illness and disease. The World Health Organization (WHO) refers to hygiene as conditions and practices that help to maintain health and prevent the spread of diseases.

Educate, Vaccinate, Evaluate
Infectious diseases are spread directly or indirectly from an infected individual. Athletes interact closely with teammates, opponents, and team staff. In addition, they frequently share training and gym equipment, facilities-training rooms/grounds, accommodation, housing, towels, water bottles and supplies and commonly undertake both domestic and international travel. Furthermore, international travel exposes athletes to indigenous diseases for which they may have little or no natural immunity. Finally, there is some information to suggest that athletes tend to be risk takers which may increase their risk for acquiring infections.

The categories of potential risk factors for spreading infection are:

• Sharing of equipment, training facilities
• Skin injury
• Close contact – on field of play, accommodations
• Off the field of play – travel, personal activities
• Diverse populations
• Infections can be transmitted by person to person contact, by common source exposure or by vector-borne transmission

The primary focus of attention should be on primary prevention by use of hygiene measures, use of immunization (vaccinations) and use of interventions to prevent secondary spread of infection. Secondary prevention measures include prevention of recurrence and prevention of onward spread of infection from a source patient.

Education of players and staff in key aspects of infection is a key element of prevention.

Hygiene Measures

Refer to WWR Medical Guideline-Bodily Fluid for specifics in this subject.

Standard Precautions
Standard precautions combine the major features of Universal Precautions and Body Substance Isolation. They are based on the principle that all blood, body fluids, secretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions include a group of infection prevention practices that apply to all individuals regardless of suspected or confirmed infection status. Key features of standard precautions, include:

• Wearing gloves when touching biohazardous material such as open skin, body fluids of mucus membrane
• Washing hands with soap and hot water after contact with above even if gloves are used
• Cleaning surfaces thoroughly with diluted bleach (10{f611f693713f4a1bfda8cd25b372c35825df95e4c1b9553b221a9b1bb44db509} solution)
• Placing sharps in a biohazard puncture proof container
• Covering any wound before going to field of play

Disinfection of Equipment
Equipment must be handled in a manner to prevent transmission of infectious agents including proper cleaning and sterilization of reusable equipment.

Guidelines for the proper disinfection and maintenance of whirlpools, saunas, ice machines and swimming pools are provided by the Occupational Safety and Health Administration (OSHA), USA. Use diluted bleach 10{f611f693713f4a1bfda8cd25b372c35825df95e4c1b9553b221a9b1bb44db509} solution (one part bleach in 9 parts water) to cleanse training areas and equipment. 

Routine cleaning schedules for shared equipment should be established and recommended. 

Equipment that has had contact with blood and body fluids should be washed with diluted bleach as above. Any towel or other material that is contaminated with blood should be laundered appropriately. 

It is always a good practice to know and follow the guidelines of the manufacturer’s recommendations.

Personal Hygiene
Good personal hygiene helps reduce colonization of bacteria. Regular handwashing is key in preventing spread of infection. Handwashing with soap for 15-30 seconds, 30 second rinse with water followed by complete drying with a towel is necessary. The use of rinses and gels with concentrations of 50-95{f611f693713f4a1bfda8cd25b372c35825df95e4c1b9553b221a9b1bb44db509} alcohol take 15 seconds to use and are effective at killing organisms. Chlorhexidine soap has been useful for reducing transmission of MRSA infections. Educate players and staff on handwashing.

For prevention of transmission of other infections transmitted by droplet/aerosol, oral-fecal route, see individual infections section.

Common Infections

1. Skin and Soft Tissue Injury
Any athlete with a skin injury (abrasion, laceration, etc.) should be removed from the field of play until the area of injury can be securely covered with occlusive dressings or bandages to prevent leakage of body fluid and to protect the lesion from becoming infected. Careful attention should be paid to the wound care after play to avoid skin infection.

Team doctors should strongly encourage and educate team members about good overall and hand hygiene, the importance of covering wounds, and the benefits in terms of infection transmission and limiting sharing of equipment. An ample supply of soap and alcohol based gels or hand rinses should be freely available. Athletes should be educated in recognizing wounds that are potentially infected and in seeking medical attention for the same.

2. Urinary Tract Infection (UTI)
UTI is a common infection usually caused by bacteria but can occur with fungal sources.  It is common in persons who utilize catheters to empty out their bladder such as indwelling catheters or those performing intermittent catheterization.  Symptoms include, but are not limited to, fever, burning sensation, increase in frequency of urination, unexpected leakage, bladder spasming, cloudy or foul odor urine, or blood in urine.  Those with complete spinal cord injury may not exhibit any symptoms.

The infection is usually treated with simple antibiotics.

3. Respiratory Infection
Most common infection is the “flu” which is caused by various viruses. Symptoms can include runny nose, congestion, fever, and malaise.  Allergies, such as seasonal or dust, can have similar symptoms.

Treatment is generally supportive.  Your medical provider can also provide anti-flu (viral) medications as well.  Yearly flu vaccination is recommended.

Many athletes in WWR have higher risk or compromised respiratory function compared to their able body counterparts.  This puts them at higher risk to get pulmonary infection.  Symptoms can include shortness of breath, difficulty breathing, and fever. It is recommended that you seek medical attention as soon as possible to have your symptoms worked up and diagnosed for appropriate treatment.

4. Fungal Infection
Fungal infections, usually skin related, are commonly transmitted in crowded settings such as public showers, locker rooms, and dormitories.  It is also transmitted through skin to skin contact as well as through shared equipment.  You may see a small skin lesion, usually flat but can be raised, that grows in size and also spreads over time. Sometimes the initial sign is a simple discoloration of the skin.

5. Blood Borne Infections
Blood borne infections are transmitted by exposure to blood from bleeding gums, substance misuse, unprotected sexual contact, and travel to endemic areas.

Based on risk, it is now recommended that individual water containers be available for each player in contact sports. Athletes should use squeeze water bottles which they do not put in their mouth.

6. Meningitis
In cases of meningococcal meningitis, chemoprophylaxis should be considered in household contacts and anyone directly exposed to the patient’s oral secretions and should be administered within the first few days of the patient’s illness. Prevention measures include use of meningococcal vaccination per international immunization guidelines.

Immunizations

Immunization is an important aspect of prevention of infection for all individuals. The following are important issues to consider in assessing disease prevention in athletes: 

• Routine health maintenance
• Catch up immunization for missed or failed primary immunization
• Travel related immunization (geographical variation for requirements)
• Recent exposure to infectious agents
• Immunization of high risk groups (eg. splenectomy, immunocompromised, etc.)

Travel-related immunization requirements will be determined by the destination of travel. Players and staff should also be opportunistically advised of standard travel-related issues such as sun exposure, driving, jet-lag prevention, sexual health. Reputable travel sites which will provide up-to-date infection outbreak information should be used to guide immunization recommendations.

Documents:
www.cdc.gov/travel
www.who.int/ith/en

Conclusion

Team doctors and managers should strongly encourage and educate team members about good overall hygiene measures and specifically hand hygiene, the importance of covering wounds, and the benefits in terms of infection transmission and limiting sharing of equipment.

An ample supply of soap and alcohol-based gels or hand rinses should be freely available. Athletes should be educated in recognizing wounds that are potentially infected and in seeking medical attention for the same.

Acknowledgement of commonly encountered infections is paramount to the recognition, management and development of prevention strategies. As described, primary prevention of infection can be promoted through accurate immunizations, appropriate planned health maintenance, good hygiene practices and behavioural modification to minimize high-risk activities.

Secondary prevention is achieved through vigilant surveillance for reportable diseases, proper education and containment for reducing infection if an illness has occurred and timely prophylaxis with medications and immunizations where indicated. Hence – Educate, vaccinate, evaluate

Download the WWR Hygiene Guidelines

Contributors:
Kenneth Lee, MD
Chief of Spinal Cord Injury Division, Clement J Zablocki VA Medical Center, Milwaukee, WI

Methicillin-resistant Staphylococcus aureus (MRSA) Infections
Methicillin-resistant Staphylococcus aureus (MRSA) is a bacteria that is resistant to many antibiotics. In the community, most MRSA infections are skin infections.

In medical facilities, MRSA causes life-threatening bloodstream infections, pneumonia and surgical site infections.

Who is at Risk, and How is
MRSA Spread in the Community?

Anyone can get MRSA through direct contact with an infected wound or by sharing personal items, such as towels or razors, that have touched infected skin. MRSA infection risk can be increased when a person is in certain activities or places that involve crowding,

skin-to-skin contact, and shared equipment or supplies. This might include athletes, daycare and school students, military personnel in barracks, and people who recently received inpatient medical care.

How Common is MRSA?

Studies show that about one in three people carry staph in their nose, usually without any illness.

Two in 100 people carry MRSA. There is no data showing the total number of people who get MRSA skin infections in the community.

Can I Prevent MRSA? How?

There are the personal hygiene steps you can take to reduce your risk of MRSA infection:

• Maintain good hand and body hygiene. Wash hands often and clean body regularly, especially after exercise.
• Keep cuts, scrapes, and wounds clean and covered until healed

• Avoid sharing personal items such as towels and razors
• Get care early if you think you might have an infection
• Wash and clean all athletic gear regularly, clothing, arm sleeves, etc.

What are MRSA Symptoms?

Often, people first think the area is a spider bite; however, unless a spider is actually seen, the irritation is likely not a spider bite. Most staph skin infections, including MRSA, appear as a bump or infected area on the skin that might be:

• Red
• Swollen
• Painful
• Warm to the touch
• Full of pus or other drainage
• Accompanied by a fever

What Should I Do If I
See These Symptoms?

If you or someone in your family experiences these signs and symptoms, cover the area with a bandage, wash your hands, and contact your doctor.

It is especially important to contact your doctor if signs and symptoms of an MRSA skin infection are accompanied by a fever.

What Should I Do If I
Think I Have a Skin Infection?

You can’t tell by looking at the skin if it is a staph infection (including MRSA).

Contact your doctor if you think you have an infection so it can be treated quickly. Finding infections early and getting care will decrease the chance that the infection will become severe.

Signs of infection include redness, warmth, swelling, pus, and pain at sites where your skin has sores, abrasions, or cuts. Sometimes these infections can be confused with spider bites.

Infections can also occur at sites covered by body hair or where uniforms or equipment cause skin irritation or increased rubbing.

Do not try to treat the infection yourself by picking or popping the sore.

Cover possible infections with clean, dry bandages until you can be seen by a doctor, nurse, or other health care provider such as an athletic trainer.

How to Prevent Spreading
MRSA If You Have MRSA

Cover your wounds. Keep wounds covered with clean, dry bandages until healed. Follow your doctor’s instructions about proper care of the wound. Pus from infected wounds can contain MRSA so keeping the infection covered will help prevent the spread to others. Bandages and tape can be thrown away with the regular trash.

Clean your hands often. You, your family, and others in close contact should wash their hands often with soap and water or use an alcohol-based hand rub, especially after changing the bandage or touching the infected wound.

Do not share personal items. Personal items include towels, washcloths, razors, clothing, and uniforms.

Wash used sheets, towels, and clothes with water and laundry detergent. Use a clothes dryer to dry them completely.

Wash clothes according to the manufacturer’s instructions on the label.

How are MRSA Skin Infections Treated?

Treatment for MRSA skin infections may include having a healthcare professional drain the infection and, in some cases, prescribe an antibiotic. Do not attempt to drain the infection yourself – doing so could worsen or spread it to others. If you are given an antibiotic, be sure to take all of the doses (even if the infection is getting better), unless your doctor tells you to stop taking it.

Source: www.cdc.gov/mrsa/

Download the WWR-MRSA Guidelines

Contributors:
Kenneth Lee, MD
Chief of Spinal Cord Injury Division, Clement J Zablocki VA Medical Center, Milwaukee, WI

Jim Murdock
Medical Coordinator / Athletic Trainer USA Wheelchair Rugby

The physiology of exercise includes more than just energy production. Athletic performance depends on proper nutrition for growth and development and for effective immune system function. Our understanding of the interrelated roles of dietary carbohydrate, protein, and fat on athletic performance has increased tremendously in the past decade.

The implementation of these new understandings and practices uniquely specific to varying levels and areas of sport, have gained attention and trust given their effectiveness in performance, recovery, and general health in the wheelchair (WC) rugby population.

Nutrition in Adaptive Sports

Sports nutrition concepts and practices have significantly evolved over the past two decades. Presently, nutrition recommendations are tailored specifically to each athlete based on a number of factors including age, gender, sport, training status, body composition, and sporting goals.

While individualized nutrition prescription is of high importance in all sports, it is more crucial in the WC rugby population due to athletes’ varying metabolic, clinical, and practical needs associated with their level/type of injury/impairment. Sports nutrition can be applied across the spectrum of athletic endeavour; from the developmental athlete, to general fitness and weight management, to the elite performer.

Nutrition goals within adaptive sports generally include an achievement of optimal training capacity and performance, achievement of appropriate body composition, promotion of health and well-being, decreasing the risk for illness and/or injury, all while preserving a healthy relationship with food and overall “food experience.”

Training Nutrition Goals

Just as an athlete will complete appropriate medical clearance and assessment by a physician, physical therapist, and/or occupational therapist, a thorough nutrition assessment is essential. A complete nutrition assessment creates a strong foundation for WC rugby athletes to maximize training, performance, and overall health. This should be conducted by a qualified practitioner (sports dietitian or equivalent) with experience in Para Sport.

An in-depth nutrition assessment and nutrition-focused physical exam includes the evaluation of:

• Anthropometric measurements
  • Height
  • Weight
  • Waist/hip/limb circumference
  • Body fat distribution (skinfold measurements or DEXA scan data)
  • Usual body weight/weight history
• Pertinent conventional and functional laboratory markers (CBC, HgbA1c, glucose, lipid panel, micronutrient levels, etc.)
• Complete medical history (including level of injury/type of impairment, etiology of impairment, time of onset, etc.)
• Current dietary habits/food preferences/food allergies, intolerances, or sensitivities/eating environment
• Assessment of total caloric intake and macronutrient (protein, carbohydrates, and fat) and micronutrient distribution (vitamins and minerals)
• Medication/supplement review

Determining Caloric Needs

Estimating energy expenditure and energy needs of an athlete can be a complex task, even if measurement tools are individualized. Given the complexity of varying injury/impairment levels, estimating energy expenditure in WC rugby athletes can pose even more difficulty, especially since wearable technologies aren’t valid for most WC rugby athletes.

Resting energy expenditure of international level wheelchair rugby players have been measured to range from 1324-2068 kcal/day, and are higher than less well-trained players. The variation in requirements is predictably large due to differences in the presence or not of a spinal cord injury (highest in non-SCI players), and the level and completeness of spinal cord lesion. There are also large variations in energy expenditure of exercise according to impairment, training status, and the player’s role on the field of play.

An experienced nutrition practitioner will be able to use tools available to them including prediction equations (e.g., Cunningham) or indirect calorimetry to estimate the individual caloric needs of players in order to guide dietary intake. However, it’s generally useful to simply start with the current intake of the athlete and make adjustments from there, especially if they’re fairly weight stable. Over time, the practitioner and athlete would work together to adjust these estimated needs (including breakdown of macronutrients) based on performance, and training capacity/ consistency and body composition changes.

Performance Nutrition For Wheelchair Rugby

Hydration
Commencing exercise in a well-hydrated state is important, as is maintaining appropriate hydration across the day, especially when traveling. Urine colour and output volume is a practical indicator of hydration status. Some athletes may deliberately restrict their fluid intake prior to training due to the practicalities of toileting once strapped-up and in their playing chair, hence educating athletes around the importance of adequate hydration status for both performance and health and working with them to develop a more effective hydration plan is essential.

Many athletes competing in WC rugby have a Spinal Cord Injury (SCI) which results in impaired sweating and blood flow responses to exercise, causing increased heat strain. These athletes will tend to have much lower sweat rates (sometimes no sweat response), resulting in lower fluid requirements. Therefore, unlike many able-bodied sports, the messaging around hydration is distinctly different. Athletes may need to utilize cooling strategies prior to and during exercise to manage heat stress (e.g., iced-towels, spray bottles, and fans), rather than simply “drinking to thirst”. It is important for practitioners and athletes to understand their individual fluid needs by undertaking sweat rate testing during training sessions, and set fluid intake plans accordingly. Prior to exercise, athletes should practice regular voiding of the bladder/catheter bag so as to decrease pressure on the bladder during the event (and decrease the likelihood of autonomic dysreflexia as much as possible). In some instances, fluid intake may need to be reduced to better match sweat rates and reduce the risk of autonomic dysreflexia.

Fuel
The determinants of an athlete’s need to consume fuel throughout the day, and specifically prior to, during, and after training include their training status (the intensity, type, and duration of training session), timing of subsequent training sessions, purpose of training sessions, as well as lifestyle activities (what is done outside of sport/training). Due to the large physiological differences between athletes, fueling strategies must be tailored to each individual. A sports nutrition practitioner can educate the athlete on how to appropriately select specific foods to best fit their needs during training, competition, and recovery periods. 

Carbohydrate is the predominant fuel used during moderate to high intensity exercise. Since wheelchair rugby involves bursts of high intensity activity with short rest periods in between, it is important to ensure adequate carbohydrate supply. The amount and timing of this carbohydrate in the diet depends on how often the athlete is training – more is required when there are multiple training sessions or games in one day (such as at a training camp or tournament). For athletes who are training 2-3 days per week and playing once a week, consuming a source of carbohydrate at each meal throughout the day will be sufficient for fuelling needs. Athletes who train/play more than once a day will need to increase their carbohydrate intake and be aware of timing it effectively before exercise, in the recovery period after a session, and potentially during a training session/game (such as a carbohydrate-electrolyte drink, banana, or bar). Nutrient-dense, carbohydrate-rich foods include fruit, starchy vegetables (e.g., potatoes, carrots, turnips, corn), legumes, whole-/sprouted grains (e.g., rice, quinoa, millet, barley, oats, and grain products [crackers, bread, etc.]), and some dairy products (yoghurt and milk).

Protein
Protein plays an important role in promoting muscle recovery and adaptations after exercise, growth and development, and immune function. Distributing moderate servings of protein intake evenly throughout the day, including post-training, optimizes day-to-day recovery from training sessions. Protein-rich foods include meat, poultry, fish/seafood, eggs, dairy products, nuts/seeds, and legumes.

Post-Exercise Recovery
Consuming ~20 grams of high-quality protein within 1-2 hours after exercise helps to boost the training response. This can be provided as a fluid, snack, or as a component of a meal. It is often observed that post-workout fuel in the form of a liquid is well-tolerated, transportable, and easy to administer (e.g., smoothie made with frozen fruit, leafy greens, nut butter, seeds [e.g., chia seeds, ground flax seeds, etc.], and liquids such as water, coconut water, cow’s milk, or nut milk; if appropriate, protein powder [or equivalent] may be added to help meet macronutrient needs).

Sample Menu For Wheelchair Rugby Athletes

Based on both athletic and health-related goals and performance output, athletes should have their individual calorie and fluid needs measured/estimated by an experienced sports nutrition practitioner. The below menu provides a framework of eating patterns and meal composition across the day.

Build meals with the following general guidelines:

Breakfast/Lunch/Dinner:

• Carbohydrate source – e.g., fruit, starchy vegetables (e.g., potatoes, carrots, pumpkin/squash, peas, etc.), whole-/sprouted grains (e.g., quinoa, millet, rice, oats, corn, etc.), legumes, etc.
  Note: The amount of carbohydrate should reflect the training loads.
  
• Protein source – e.g., chicken, turkey, fish/seafood, red meat, eggs, legumes, tofu, dairy, and nuts/seeds
  
• Non-starchy vegetables – e.g., spinach, kale, capsicum/peppers, celery, cucumber, onion, radish, Brussels sprouts, green/red cabbage, cauliflower, eggplant, etc.
  Note: Ensure variety and different colors
  
• Nourishing fat source – e.g., avocado, raw nuts, seeds, oil (avocado, walnut, olive, coconut, etc.), salmon, egg yolk, dairy
  
• Water

Snacks:

• Pair carbohydrate source with quality protein/fat source if possible
  
• Pre-training: Carbohydrate foods should form the basis of pre-training snacks. If your training session falls after a meal (e.g., mid-morning), it may be that your previous meal will serve this pre-training purpose (i.e., breakfast). If a snack is required, simple snacks (that pair carbohydrate with a protein/fat source) such as a piece of fruit with nut butter or raw nuts, crackers with spread, dried fruit with cheese, or a nutrient-dense bar are appropriate. Gut comfort of the athlete should always be considered with pre-training food choices.
  
• Post-training: Protein (~20 grams) should form the basis of your post-training snack or meal and should be consumed within 1 to 2 hours of training. If a meal is not due within this time, practical snacks include high-protein yoghurt, a wrap with protein filling, or a smoothie.

Sample Meal Plan

Breakfast

• Oatmeal: Oats (rolled oats, cooked in water, cow’s milk, nut milk, or equivalent)
  Toppings: Natural nut butter, raisins, cinnamon, etc.
  
• Fresh berries (strawberries, blackberries, blueberries, raspberries, etc.) or other fruit
  
• Egg(s) (scrambled, hard-cooked, poached, over-easy, etc.) with sauteed greens or other vegetable(s)

Snack
Yoghurt bowl:

• Plain Greek yoghurt
• Nuts and/or seeds (e.g., ground flax seed, pumpkin seeds, chia seed, etc.)
• Fresh berries (strawberries, blackberries, blueberries, raspberries, etc.) or other fruit

Lunch
Sandwich/wrap:

• Whole-/sprouted grain bread/wrap/tortilla/etc.
• Turkey, chicken, beef, or other quality protein source
• Add leafy greens, tomatoes, cheese, etc.
• Dill pickle or sauerkraut
• Side salad

or Stirfry:

• Chicken, turkey, beef, fish/seafood, or other quality protein source
• Vegetables
• Rice/noodles
• Fruit
• Kefir

Snack
Smoothie:

• Frozen cherries or berries
• Banana
• Natural nut butter
• Chia seeds, ground flax seed, etc.
• Spinach or other leafy greens
• Water, coconut water, cow’s milk, nut milk, or equivalent
• Note: Add protein powder or equivalent if appropriate
• Raw nuts (almonds, walnuts, pistachios, cashews, pecans, etc.)

Dinner

• Wild-caught fish (or other quality protein source)
• Baked potato or other starchy carbohydrate source
• Fresh fruit
• Non-starchy vegetable and/or salad: Salad greens (spinach, kale, collard greens, Swiss chard, arugula, etc.), sliced vegetables, raw nuts/seeds, vinaigrette dressing
• Dark chocolate (>70{f611f693713f4a1bfda8cd25b372c35825df95e4c1b9553b221a9b1bb44db509} cocoa)

Contributors:

Samantha Schleiger, MS, RDN, CD, CLT
Adaptive Sports Clinic, Spinal Cord Injury Division,
Clement J Zablocki VA Medical Center, Milwaukee, WI, USA.

Elizabeth (Liz) Broad, PhD, APD, FSDA
Independent sports dietitian, NSW, Australia.

Siobhan Crawshay, BND, APD
Paralympics Australia, Melbourne Australia.

Jordan Fenton, MSc, PhD
Researcher at Peter Harrison Centre for Disability Sport,
Loughborough University, UK.

Kenneth Lee, MD
Associate Professor, Dept of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA.

Vicky Tolfrey, PhD
Professor/Director, Peter Harrison Centre for Disability Sport, Loughborough University, UK

References:

• Broad, E. (2019). Sports Nutrition for Paralympic Athletes (2nd ed.). Taylor & Francis.
• Broad E.M., Newsome L.J., Dew D.A., Barfield J.P. Measured and predicted resting energy expenditure in wheelchair rugby athletes. J. Spinal Cord Med. 2020;43:388-397.
• Karpinski, C., & Rosenbloom, C. (2017). Sports nutrition: A handbook for professionals (Sixth ed.). Chicago, IL: Academy of Nutrition and Dietetics.
• Pritchett K., Broad E., Scaramella J., Baumann S. Hydration and cooling strategies for Paralympic athletes. Curr. Nutr. Rep. 2020;9:137-146 – Link
• Thomas DT, Erdman KA, Burke LM. Position of the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: nutrition and athletic performance. J Acad Nutr Diet. 2016;116(3):501-528. PMID: 26920240 – Link

Download the WWR Adaptive Sports Nutrition Guideline

Over the years a tremendous amount of research has been conducted on wheelchair rugby and those who play the sport. Most of the research is conducted by doctors, universities, and students in an effort to better understand the demands and effects of sport on athletes with a disability.

If you are a scientist or researcher and would like to share your article/work here with the wheelchair rugby community, please contact WWR at info@worldwheelchair.rugby.

All research links are provided for the interest of wheelchair rugby enthusiasts and do not form any WWR policy, procedure or guidelines.

To help keep the global wheelchair rugby family informed WWR will add new links to this Research Library as they become available. If you find that only the abstract of a document is available, please contact the author/publisher to request the full article.

Classification

• Mason et al. (2019). Understanding the Impact of Trunk and Arm Impairments on Wheelchair Rugby Performance During Competition. Int J Sports Physiol Perform, 14(5), 612-619. – Link
• Validity and reliability of isometric tests for the evidence-based assessment of arm strength impairment in wheelchair rugby classification. – Link

• Effects of Trunk Impairments on Manual Wheelchair Propulsion Among Individuals with a Spinal Cord Injury: A Brief Overview and Future Challenges
• Towards evidence-based classification in wheelchair sports: Impact of seating position on wheelchair acceleration – Link
• The Impact of Trunk Impairment on performance of wheelchair activities with a focus on wheelchair court sports: a systematic review – Link

Equipment

• Rolling Friction of a Rugby Wheelchair – Download as PDF courtesy Dr. Franz Fuss
• The Effects of Rear-Wheel Camber on Maximal Effort Mobility Performance in Wheelchair Athletes – Link
• Influence of Glove Type on Mobility Performance for Wheelchair Rugby Players – Link

Game Analysis

• Rhodes et al. (2015). Activity Profiles of Elite Wheelchair Rugby Players During Competition. Int J Sports Physiol Perform, 10(3), 318-324. – Link
• Rhodes et al. (2015). Effect of Team Rank and Player Classification on Activity Profiles of Elite Wheelchair Rugby Players. J Sports Sci, 33(19), 2070-2078. – Link

• Game efficiency of wheelchair rugby athletes at the 2008 Paralympic games with regard to player classification – Link
• Tracking of wheelchair rugby players in the 2008 Demolition Derby final – Link

Health Care

• Effects of Spinal Cord Lesion Level upon Thermoregulation during Exercise in the Heat – Link or Download as PDF courtesy Dr. Michael Price
• Shoulder Pain: A Comparison of Wheelchair Athletes and Nonathletic Wheelchair Users – Download as PDF courtesy Dr. Heather Fullerton

• The Relationship of Strength and Muscle Balance to Shoulder Pain and Impingement Syndrome in Elite Quadriplegic Wheelchair Rugby Players – Link

Performance

• Goosey-Tolfrey et al. (2018). Sprint Performance and Propulsion Asymmetries on an Ergometer in Trained High- And Low-Point Wheelchair Rugby Players. Scan J Med Sci Sports, 28(5), 1586-1593. – Link

• Objective Measurement of Ball-Handling Proficiency in Wheelchair Sports: A systematic Review. Viola c. Altmann Et al Link

Strength & Conditioning

• Effects of heavy resistance training on strength and power in upper extremities in wheelchair athletes – Link or
  Download as PDF courtesy Dr. Stephan Schiemann
• Exercise intensity during wheelchair rugby training – Download as PDF courtesy Dr. J.P. Barfield
• Quad Rugby – A Strength and Conditioning Training Guide for Elite Players – Download as PDF courtesy Dr. Dawn Gulick

• The Relationship of Strength and Muscle Balance to Shoulder Pain and Impingement Syndrome in Elite Quadriplegic Wheelchair Rugby Players – Link
• Energy expenditure in ball games for wheelchair users – Link

Training

• Rhodes et al. (2017). A Comparison of Speed Profiles During Training and Competition in Elite Wheelchair Rugby Players. Int J Sports Physiol Perform, 12(6), 777-782. – Link
• Rhodes et al. (2018). Altering the Speed Profiles of Wheelchair Rugby Players With Game-Simulation Drill Design. Int J Sports Physiol Perform. 13(1),37-43. – Link

• Paulson et al. (2015). Individualized Internal and External Training Load Relationships in Elite Wheelchair Rugby Players. Frontiers Physiol, 6,388. – Link

Thermoregulation/Physiology

• Griggs et al. (2017). Thermoregulatory Responses During Competitive Wheelchair Rugby Match Play. Int J Sports Med, 38(3), 177-183. – Link
• Griggs et al. (2017). Effects of Cooling Before and During Simulated Match Play on Thermoregulatory Responses of Athletes With Tetraplegia. J Sci Med Sport, 20(9), 819-824. – Link

• West et al. (2014). Effect of Abdominal Binding on Respiratory Mechanics During Exercise in Athletes With Cervical Spinal Cord Injury. J Appl Physiol, 117(1), 36-45. – Link

Social Life

• “I Can’t Be Standing Up Out There”: Communicative Performances of (Dis)Ability in Wheelchair Rugby – Download as PDF courtesy Dr. Kurt Lindemann
• Communicating In and Through ‘‘Murderball’’: Masculinity and Disability in Wheelchair Rugby – Download as PDF courtesy Dr. Kurt Lindemann

• Wheelchair exercise performance of the young, middle-aged, and elderly – Link

A player’s classification, impairment type and physical attributes all contribute to the predisposition of heightened thermal strain in wheelchair rugby. The downloadable document provides suggested cooling methods available alongside optimal timings.

Download Link